Temporary inferior vena cava filters factors associated with non-removal.

OBJECTIVES: Inferior vena cava filter (IVCF) placement is indicated when there is a deep vein thrombosis and/or a pulmonary embolism and a contraindication of anticoagulation. Due to the increased risk of recurrent deep venous thrombosis when left in place, IVCF removal is indicated once anticoagulant treatment can be reintroduced. However, many temporary IVCF are not removed. We aimed to analyze the removal rate and predictors of filter non-removal in a university hospital setting. METHODS: We collected all the data of consecutive patients who had a retrievable IVCF inserted at the Saint-Etienne University Hospital (France) between April 2012 and November 2019. Rates of filter removal were calculated. We analyzed patient characteristics to assess factors associated with filter non-removal, particularly in patients without a definitive filter indication. The exclusion of this last category of patients allowed us to calculate an adjusted removal rate. RESULTS: The overall removal rate of IVCF was 40.5% (IC 95% 35.6-45.6), and the adjusted removal rate was 62.9 % (IC 95% 56.6-69.2%). No major complications were noted. Advanced age (p < 0.0001) and cancer presence (p < 0.003) were statistically significant predictors of patients not being requested to make a removal attempt. CONCLUSIONS: Although most of the filters placed are for therapeutic indications validated by scientific societies, the removal rate in this setting remains suboptimal. The major factors influencing IVCF removal rate are advanced age and cancer presence. KEY POINTS: • Most vena cava filters are placed for therapeutic indications validated by scientific societies. • Vena cava filter removal rates in this setting remain suboptimal. • Major factors influencing IVCF removal rate are advanced age and cancer presence.

Pathological Analysis and Clinical Evolution After Radiological Removal of Retrievable Vena Cava Filters.

OBJECTIVE: Retrievable inferior vena cava filters (IVCF) have been developed because permanent filters have been associated with an increased risk of recurrent deep venous thrombosis. There is no data on the interactions of IVCF with the inferior vena cava (intrafilter thrombi, insertion through the venous wall) even though this may alter the course after retrieval of the IVCF. METHODS: A review of 85 consecutive patients undergoing retrieval of IVCF placed at a single center was performed from January 1, 2010 and December 31, 2014. Inferior vena cava filter were examined for presence of intrafilter thrombus at time of retrieval. Filter position and presence of intraluminal thrombus were examined. Patient outcomes, including recurrence of deep vein thrombosis (DVT) and death, were captured at 3 month followup. RESULTS: Eighty five patients were identified, with intrafilter thrombi found in 69 (81%) patients and venous wall fragments found in 75 (88%) patients. However, their presence was not associated with an increased risk of recurrent venous thromboembolism (VTE) or death during follow up. CONCLUSIONS: Intrafilter thrombi and venous wall fragments are frequently found in removed IVCF but are not associated with a worse prognosis. They may not modify the therapeutic management of patients.

Combination of Percutaneous Screw Fixation and Cementoplasty for Lytic Bone Metastases: Feasibility, Safety and Clinical Outcomes.

OBJECTIVE: To evaluate feasibility, safety and efficacy of a combination of screw fixation and cementoplasty for pathologic bone fracture. METHODS: In this single-center prospective study, all consecutive percutaneous screw fixations under assisted CT guidance for palliation and fracture treatment of pathologic bone fracture were reviewed from July 2019 to February 2021. The primary outcome measure was the procedures' technical success, defined as the correct placement of the screw(s), without any complications. Secondary outcome measures were the safety, the procedures' early analgesic effects and impacts on quality of life at 4 weeks. RESULTS: Technical success was achieved in 11/11 procedures (100%) among 11 patients. No major complications attributable to the procedure were noted. The mean pain scored significantly decreased at the initial follow-up: 8.0 ± 2.7 versus 1.6 ± 2.5 (p < 0.05). Opioid doses were statistically lower after procedure: 70.9 ± 37 versus 48.2 ± 46 mg/day (p < 0.05). The mean EQ5D score had significantly increased by the early post-procedure consultation: 42.5 ± 13.6 vs 63.6 ± 10.3 (p < 0.05). CONCLUSION: Combination of percutaneous screw fixation and cementoplasty for pathologic bone fracture is feasible and safe. It is efficient to reduce pain, decrease the consumption of opioids and improve the quality of life at 4 weeks after the procedure.

Percutaneous screw fixation and cementoplasty of metastatic sternal fracture: Descriptions of 2 cases.

Secondary lesions and hemopathy localized in sternal bone may be responsible for persistent pain and resistant to classical analgesics. Surgical treatment is not applicable in these cases. We report on 2 cases of sternal osteosynthesis by internal cemented screw fixation, under fluoroscopy and CT scan control, without complication and with clear, immediate reduction of pain. Cementoplasty alone does not appear to be the most appropriate approach for treating lytic sternal lesions which are subject to traction and distraction forces, and resistant to analgesics. Discussion of these 2 cases demonstrate that internal cemented screw fixation allows for rapid management of pain in lytic lesions of the sternum in cancer-related context and should be more widespread in the medical community.

Safety and efficacy of emergency transarterial embolization for mesenteric bleeding.

BACKGROUND: Patients with spontaneous or traumatic active mesenteric bleeding cannot be treated endoscopically. Transarterial embolization can serve as a potential alternative to emergency surgery. Literature on transarterial embolization for mesenteric bleeding remains very scarce. The objective of this study was to evaluate the safety and efficacy of transarterial embolization for mesenteric bleeding. We reviewed all consecutive patients admitted for mesenteric bleeding to the interventional radiology department, in a tertiary center, between January 2010 and March 2021. Mesenteric bleeding was defined as mesenteric hematoma and contrast extravasation and/or pseudoaneurysm visible on pre-operative CT scan. We evaluated technical success, clinical success, and complications. RESULTS: Among the 17 patients admitted to the interventional department for mesenteric bleeding, 15 presented with active mesenteric bleeding requiring transarterial embolization with five patients with hemodynamic instability. Mean age was 67 ± 14 years, including 12 (70.6%) males. Technical success was achieved in 14/15 (93.3%) patients. One patient with technical failure was treated by percutaneous embolization with NBCA-Lipiodol mixture. Three patients (20%) had early rebleeding: two were treated by successful repeat embolization and one by surgery. One patient (6.7%) had early death within 30 days and two patients (13.3%) had late death after 30 days. Mean length of hospitalization was 12.8 ± 7 days. There were no transarterial embolization-related ischemic complications. CONCLUSION: Transarterial embolization is a safe and effective technique for treating mesenteric bleeding even in patients with hemodynamic instability. Transarterial embolization doesn't close the door to surgery and could be proposed as first intention in case of mesenteric bleeding.

Preventive tract embolization with gelatin sponge slurry is safe and considerably reduces pneumothorax after CT-guided lung biopsy with use of large 16-18 coaxial needles.

OBJECTIVE: To evaluate the clinical impact of the tract embolization technique using gelatin sponge slurry after percutaneous CT-guided lung biopsy. METHODS: We retrospectively compared coaxial needle CT-guided lung biopsies performed without embolization (100 patients) and with the tract embolization technique using a mixture of iodine and gelatin sponge slurry (105 patients) between June 2012 and July 2020. Uni- and multivariate analyses were performed between groups to determine risk factors of pneumothorax. RESULTS: Patients with gelatin sponge slurry tract embolization had statistically lower rates of pneumothorax ((17.1% vs 39%, p < 0.001). In univariate analysis, tract embolization (OR = 0.32, CI = 0.17-0.61 p<0.001) and nodule size >2 cm (OR = 0.33 CI = 0.14-0.8 p = 0.013) had a protective effect on pneumothorax. The puncture path lengths > 2-20 mm and >20 mm were risk factors for pneumothorax (OR = 3.35 IC = 1.44-8.21 p = 0.006 and OR = 4.36 CI = 1.98-10.29 p<0.001, respectively). In multivariate regression analysis, tract embolization had a protective effect of pneumothorax (OR = 0.25, CI = 0.12-0.51, p < 0.001). The puncture path lengths > 2-20 mm and >20 mm were risk factors for pneumothorax (p = 0.030 and p = 0.002, respectively). CONCLUSIONS: The tract embolization technique using iodinated gelatin sponge slurry is safe and considerably reduces pneumothorax after percutaneous CT-guided lung biopsy. Our results suggest that it could be use in clinical routine. ADVANCES IN KNOWLEDGE: The systemic use of gelatin sponge slurry is safe and reduces considerably the rate of pneumothorax upon needle removal when CT-guided core biopsies are performed using large 16-18G coaxial needles.

Chordomas: A review with emphasis on their pathophysiology, pathology, molecular biology, and genetics.

Chordomas are uncommon, bone, axial, or (rarely) extra-axial tumors that are malignant and frequently recur but less commonly metastasize. They usually affect adults, with a very small proportion being pediatric tumors. For children, such tumors present a different biology, since they are more common as scull rather than sacral tumors, with aggressive histological features, including a loss of SMARCB1/INI1 and a dismal prognosis. Histologically, chordomas, believed to derive from notochordal tissue, characteristically show physaliphorous cells in a myxoid or chondroid matrix. Dedifferentiated and poorly differentiated forms can be observed. Moreover, a grading scale for chordomas has been proposed. Cytokeratin, EMA, S100, and brachyury are expressed by most chordomas. These are chemo-resistant tumors, for which surgical resection and/or radiotherapy are the treatments of choice. In this review, the histological, immunohistochemical, molecular, and clinical data of chordomas are discussed.

Boundary and vulnerability estimation of the internal borderzone using ischemic stroke lesion mapping.

Distinction between deep and superficial middle cerebral artery (MCA) territories and their junctional vascular area (the internal borderzone or IBZ) constitutes a predictor of stroke patient outcome. However, the IBZ boundaries are not well-defined because of substantial anatomical variance. Here, we built a statistical estimate of the IBZ and tested its vulnerability to ischemia using an independent sample. First, we used delineated lesions of 122 patients suffering of chronic ischemic stroke grouped in deep, superficial and territorial topographies and statistical comparisons to generate a probabilistic estimate of the IBZ. The IBZ extended from the insular cortex to the internal capsule and the anterior part of the caudate nucleus head. The IBZ showed the highest lesion frequencies (~30% on average across IBZ voxels) in our chronic stroke patients but also in an independent sample of 87 acute patients. Additionally, the most important apparent diffusion coefficient reductions (-6%), which reflect stroke severity, were situated within our IBZ estimate. The IBZ was most severely injured in case of a territorial infarction. Then, our results are in favour of an increased IBZ vulnerability to ischemia. Moreover, our probabilistic estimates of deep, superficial and IBZ regions can help the everyday spatial classification of lesions.

Comparison of cytology, chest computed and positron emission tomography findings in malignant pleural effusion from lung cancer.

BACKGROUND: Malignant pleural effusion (MPE) is a common medical problem in lung cancer (LC). Pleural fluid cytology (PFC), chest computed tomography (CCT) and positron emission tomography (PET) findings are helpful as first line approach. The objectives of this study were to evaluate whether there is a correlation between PFC, CCT and PET in patients with MPE due to LC. METHODS: We selected patients from our electronic files. Data of PFC, pleural biopsy (PB), CCT and PET have been recorded and analyzed. RESULTS: A total of 101 consecutive patients (66 males, 65.3%) with a mean age of 66.2±31 years were selected. Types of LC were adenocarcinoma in 71 patients (70.2%), squamous in 13 (12.8%), small-cell in 12 (11.8%) and large cell in 5 (4.9%). CCT showed nodules in 6 (5.9%), pleural thickening in 8 (7.9%) and both in 17 (16.8%) patients. PFC was positive in 55/91 thoracentesis (60.4%) and 32/52 thoracoscopy (61.5%), while PB in 38/40 performed (95%). PET fixation was found in 32/47 (68%) patients who had MPE at diagnosis. When we associate PFC to CCT and PET findings, the yield in our study becomes 90%. No correlation was observed between CCT findings and PFC (P=0.62) between PFC and PET fixation (P=0.63) or between CCT and PET (P=0.06). CONCLUSIONS: In our cohort of LC patients with MPE, we observed a high sensitivity for PFC, while in most of the cases no findings were observed in CCT. PET had a relative low sensitivity. However, when all 3 methods were combined the yield was 90%.

Incidental findings on brain magnetic resonance imaging in the elderly:the PROOF study.

To prospectively evaluate the prevalence of incidental findings on standardized brain MRI scans in a cohort of elderly subjects. All participants provided written informed consent to participate in this prospective study, which was approved by the institutional review board and was HIPAA compliant. There were 503 subjects (75.3 ± 0.9 years of age, 58 % women) who received brain MRIs on a 1.5-T scanner using a standard acquisition protocol. All scans were reviewed by an experienced neuroradiologist. Incidental findings were stratified as follows: 1, no incidental findings; 2, incidental findings without clinical significance; 3, incidental findings with clinical significance or requiring clinical follow-up. Incidental findings were identified in 77.9 % of subjects. Among 392 scans that exhibited incidental findings, 494 abnormalities were identified. The most common findings in our study were cysts (45.9 % of subjects) and ear, nose, and throat (ENT) lesions (24.8 %) followed by stroke lesions (6.6 %) and neoplasms (3.8 %). There were 472 incidental findings that lacked clinical significance (group 2), and 22 incidental findings that required follow-up evaluation (group 3). Incidental findings on brain MRIs were commonly observed in this cohort of elderly subjects, but clinical follow-up was rarely indicated.

Supra-Epiglottic Upper Airway Volume in Elderly Patients with Obstructive Sleep Apnea Hypopnea Syndrome.

OBJECTIVE: Small upper airway measurements areas and high body mass index are recognized risk factors for obstructive sleep apnea syndrome (OSAS) in non-elderly populations; however, there is limited information regarding elderly patients. We evaluated whether upper airway volume is associated with OSAS and OSAS treated with continuous positive airway pressure (CPAP) treatment and whether BMI is correlated with upper airway volume and measurements in elderly subjects. METHODS: In 60 volunteers aged 75.58±0.9 years: 20 OSAS, 20 OSAS chronically treated with CPAP, and 20 controls, semi-automatic segmentation, retropalatal distance and transverse diameter of the supra-epiglottic upper airway were evaluated using 3DT1-weighted magnetic resonance imaging. Anteroposterior to transverse diameter ratio was defined as retropalatar diameter/transverse diameter. RESULTS: There were no significant differences in supra-epiglottic upper airway volume between OSAS, CPAP treated patients, and controls. There were significant differences in retropalatal distance and anteroposterior to transverse diameter ratio between OSAS, CPAP treated patients, and controls (P = 0.008 and P<0.0001 respectively). There was a significant correlation between body mass index and retropalatal distance (P<0.05) but not with supra-epiglottic upper airway volume. CONCLUSION: In elderly subjects, OSAS and body mass index are not associated with changes in supra-epiglottic upper airway volume but are associated with modification of pharynx shape.

Visual Assessment of Age-Related White Matter Hyperintensities Using FLAIR Images at 3 T: Inter- and Intra-Rater Agreement.

BACKGROUND: Age-related white matter hyperintensities are frequent incidental findings on T2-weighted brain MRI, and they are evaluated in clinical practice using a visual rating scale. OBJECTIVE: To evaluate inter- and intra-rater agreement in MRI visual evaluations of age-related white matter hyperintensities made by two radiologists with different levels of experience using a visual rating scale. METHODS: Two radiologists of two different levels of experience separately rated age-related white matter hyperintensities in 40 consecutive 3-tesla brain MRI scans using the Fazekas and Schmidt visual rating scale. Ratings were made on axial FLAIR (fluid-attenuated inversion recovery) sequences. Two readings were made by each radiologist. Intra- and inter-rater agreement was statistically determined by using Cohen's weighted kappa analysis. RESULTS: Forty patients (21 females, 19 males; mean age = 57 ± 18.43 years) were included between September and October 2011. Mean values ± SD for visual scores were as follows: periventricular hyperintensities, between 1.175 ± 0.9 and 1.375 ± 0.89; number of deep white matter hyperintensity lesions, between 1.325 ± 1.18 and 1.575 ± 1.15, and extent of deep white matter hyperintensity lesions, between 0.925 ± 0.78 and 1.1 ± 0.74. Intra- and inter-rater agreement was very good (x03BA; values, 0.85-0.91 and 0.80-0.97, respectively) for each of the three visual scale criteria, with significant correlations between ratings (r = 0.95; p < 0.0001) and readings (r = 0.91; p < 0.0001). CONCLUSION: Visual assessment of age-related white matter hyperintensities by radiologists using a visual scale on FLAIR sequence is reproducible. Differences in experience level do not influence readings. Visual scale use is thus justified in common practice.

Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial.

IMPORTANCE: Although retrievable inferior vena cava filters are frequently used in addition to anticoagulation in patients with acute venous thromboembolism, their benefit-risk ratio is unclear. OBJECTIVE: To evaluate the efficacy and safety of retrievable vena cava filters plus anticoagulation vs anticoagulation alone for preventing pulmonary embolism recurrence in patients presenting with acute pulmonary embolism and a high risk of recurrence. DESIGN, SETTING, AND PARTICIPANTS: Randomized, open-label, blinded end point trial (PREPIC2) with 6-month follow-up conducted from August 2006 to January 2013. Hospitalized patients with acute, symptomatic pulmonary embolism associated with lower-limb vein thrombosis and at least 1 criterion for severity were assigned to retrievable inferior vena cava filter implantation plus anticoagulation (filter group; n = 200) or anticoagulation alone with no filter implantation (control group; n = 199). Initial hospitalization with ambulatory follow-up occurred in 17 French centers. INTERVENTIONS: Full-dose anticoagulation for at least 6 months in all patients. Insertion of a retrievable inferior vena cava filter in patients randomized to the filter group. Filter retrieval was planned at 3 months from placement. MAIN OUTCOMES AND MEASURES: Primary efficacy outcome was symptomatic recurrent pulmonary embolism at 3 months. Secondary outcomes were recurrent pulmonary embolism at 6 months, symptomatic deep vein thrombosis, major bleeding, death at 3 and 6 months, and filter complications. RESULTS: In the filter group, the filter was successfully inserted in 193 patients and was retrieved as planned in 153 of the 164 patients in whom retrieval was attempted. By 3 months, recurrent pulmonary embolism had occurred in 6 patients (3.0%; all fatal) in the filter group and in 3 patients (1.5%; 2 fatal) in the control group (relative risk with filter, 2.00 [95% CI, 0.51-7.89]; P = .50). Results were similar at 6 months. No difference was observed between the 2 groups regarding the other outcomes. Filter thrombosis occurred in 3 patients. CONCLUSIONS AND RELEVANCE: Among hospitalized patients with severe acute pulmonary embolism, the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months. These findings do not support the use of this type of filter in patients who can be treated with anticoagulation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00457158.

Brain magnetic resonance imaging findings in cryptogenic stroke patients under 60 years with patent foramen ovale.

PURPOSE: To compare magnetic resonance imaging (MRI) brain feature in cryptogenic stroke patients with patent foramen ovale (PFO), cryptogenic stroke patients without PFO and patients with cardioembolic stroke. MATERIALS AND METHODS: The ethics committee required neither institutional review board approval nor informed patient consent for retrospective analyses of the patients' medical records and imaging data. The patients' medical files were retrospectively reviewed in accordance with human subject research protocols. Ninety-two patients under 60 years of age were included: 15 with cardioembolic stroke, 32 with cryptogenic stroke with PFO and 45 with cryptogenic stroke without PFO. Diffusion-weighted imaging of brain MRI was performed by a radiologist blinded to clinical data. Univariate, Fischer's exact test for qualitative data and non-parametric Wilcoxon test for quantitative data were used. RESULTS: There was no statistically significant difference found between MRI features of patients with PFO and those with cardioembolic stroke (p<.05). Patients without PFO present more corticosubcortical single lesions (p<.05) than patients with PFO. Patients with PFO have more often subcortical single lesions larger than 15mm, involvement of posterior cerebral arterial territory and intracranial occlusion (p<.05) than patients with cryptogenic stroke without PFO. CONCLUSION: Our study suggests a cardioembolic mechanism in ischemic stroke with PFO.